Flight Safety Detectives

Latest Episodes:

Fatal Crashes Traced to Cirrus Pilots - Episode 241 Oct 09, 2024

Show notes

Two recent Cirrus accidents killed a total of seven people. Greg Feith, John Goglia and Todd Curtis have some advice for Cirrus pilots to avoid similar tragedies. They caution newer technology supports, but is not a replacement for, good planning and pilot decision-making.

One accident at Kill Devil Hills airport in North Carolina, killed four adults and one child. Another, in Provo, Utah airport killed both occupants.

The Kill Devil Hills aircraft apparently had the maximum possible number of occupants. Todd shares his experiences flying with a heavily loaded aircraft and how weight impacts safe flight practices.

Kill Devil Hills Airport has a relatively short runway. Planning and maintaining a stabilized approach, making adjustments for trees and towers, and factoring in weather conditions all need consideration when planning to take off and land there.

Accident investigators are urged to look into the specific training the pilot had for this Cirrus model.

In the Utah flight, the aircraft may have entered an accelerated stall and crashed during a second approach shortly after turning from the downwind leg to the base leg.

Like the first accident, ADS-B data indicated that the accident aircraft did not recently land at the accident airport. The pilot’s lack of familiarity and planning may be key factors in the crash.

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Report on Fatal Air Crash Leaves Cause a Mystery - Episode 240 Oct 02, 2024

Show notes

Fight instructor-related accidents and check ride failures at all levels of certificates and ratings are on the rise. Why? Insights are hard to come by.

The report on a February 24, 2024 fatal training flight in South Africa that killed the student pilot and the instructor does nothing to help that issue. The Flight Safety Detectives’ analysis of the document finds a lack of any insightful analysis of the factors that led to the fatal crash.

There are no useful insights or lessons that could benefit aviation safety. Any accident investigation has to provide some kind of aviation safety benefit, and this investigation did not meet that standard.

The flight involved a pre-solo student. The training manual may have included things not normally taught to a pre-solo student. Based on eyewitness testimony, the aircraft had a low and fast approach, followed by a wingover maneuver. The report does not answer the basic question of whether it was the student or instructor at the controls.

Greg Feith points out key factual evidence not analyzed or explained in the report. Todd Curtis calls for more details about the flight instructor and the flight school. John Goglia surmises that the report was written by someone without an aviation operations background.

Greg, who sits on the National Association of Flight Instructors (NAFI) board of directors, encourages the audience to attend the upcoming NAFI national safety summit, https://nafisummit.org/. The summit will address concerns over the quality of flight training.

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Anxiety in Flight Turns Deadly - Episode 239 Sep 25, 2024

Show notes

A second-in-command pilot left the cockpit and either jumped or fell out of an open rear cargo door of a CASA 212 aircraft flying over North Carolina. Digging into the details reveals he was self-medicating for anxiety and he may have been overcome by agitation during flight.

In this 2022 event, the main landing gear was damaged when the plane that was supporting sky diving tried to land. The crew diverted to a larger airport for a second landing attempt. During that diversion, the second in command was visibly upset. He left the cockpit and either intentionally or accidentally left the aircraft, falling to his death.

During the investigation, the NTSB found that this pilot was known to be a perfectionist who was hard on himself regarding his performance as a pilot.

The toxicological tests indicated that the pilot who died has mitragynine in his system, which is associated with the drug Kratom. The Food and Drug Administration has not approved Kratom for any use, and the Drug Enforcement Agency has identified Kratom as a drug of concern. Internal FAA policy considers its use disqualifying for pilots.

The probable cause for this event does not say anything about the role of Kratom or mental health issues. Addressing mental health in aviation is part of a larger societal problem that should be addressed. Aviation professionals don't have the incentive to get treatment for mental health issues because coming forward could end their career.

Related documents are available at the Flight Safety Detectives website.

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Critical Aviation Safety Issues Emerge from Voepass ATR72 Accident - Episode 238 Sep 18, 2024

Show notes

The preliminary accident report on the August 9, 2024 crash of a Voepass ATR72 near Sao Paolo, Brazil has just been issued. John Goglia, Todd Curtis and Greg Feith apply their expertise to examine the findings and critical aviation safety issues.

The report has detailed facts, including a summary of the flight, but several key pieces of information are missing. One big issue – no detailed transcript of what was said in the cockpit during the flight.
The report focuses on the aircraft's deicing and anti-icing systems, including its apparent malfunctions. This system was first activated after the crew received an alert from the aircraft's ice detection system, and was turned off less than a minute later.
The crew did not react appropriately after turning off the deicing system warning. Rather than leaving the altitude where the icing was occurring or disengaging the autopilot, the crew did neither.
Based on the portions of the crew's conversation during the flight in the report, John concludes that the crew was not paying enough attention to flying the airplane. They did not address warnings from the aircraft.
There is a potential conflict of interest that may impede getting all the details of this accident. The Brazilian Air Force runs CENIPA, the aviation accident investigative authority, and the Brazilian air traffic control organization. Greg and John share their firsthand experiences with investigators dealing with outside influences using the example of the 1994 Roselawn, Indiana ATR72 accident.
Key takeaway here: pilots, especially professional pilots, need to educate themselves about how icing affects their aircraft.

Related documents are available at the Flight Safety Detectives website.

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When Mooney Airplane Doors Open in Flight - Episode 237 Sep 11, 2024

Show notes

In March, a Mooney airplane door opened in flight, causing a loss of control and two fatalities. Todd and John examine this incident and three other Mooney events. Instead of a fault with Mooney aircraft, they find a pattern of very experienced pilots having issues and crashing when a passenger or baggage door opens in flight.

Doors open in flight often. The outcome depends on pilot action.

The pilot in the most recent crash had commercial and instrument ratings and nearly 800 hours of experience. Besides the door opening in flight, the NTSB found no other issues with the aircraft. The door alone should not have caused the plane crash.
In the earlier cases they discuss, all the pilots had at least a hundred hours of flight experience and there were no issues with the aircraft other than the doors opening in flight. One of those accidents had an instructor pilot on board, and between the student and instructor, they had over 9,000 hours of flight experience.
Todd shares an early similar flight experience when an oil access door came open during the takeoff roll. He aborted the takeoff. His current process during his flight training focuses on flying the aircraft and assessing the situation before taking any other action.

Related documents are available at the Flight Safety Detectives website.

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Takeaways from AirVenture 2024 - Episode 236 Aug 28, 2024

Show notes

Get the highlights of the Experimental Aircraft Association's AirVenture 2024 in Oshkosh, Wisconsin!

Hundreds of thousands of attendees attended the multi-day event. All sectors of aviation were represented, from the military to general aviation, from exotic and experimental aircraft to flight demonstrations by military and civilian aircraft.
John Goglia attended once again this year and chatted with pilots, mechanics, elected officials, and aviation enthusiasts of every age. He met several people who regularly listen to the podcast, including some who offered ideas for future shows.
AirVenture is a unique airshow experience, but there are opportunities to visit other airshows around the country. Many local airports also offer opportunities for the general public, to see airplanes up close and speak to local pilots, flight schools, and others involved in aviation.

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Brazilian Aviation Woes: VoePass Deadly Crash & ATC Comms Issues - Episode 235 Aug 21, 2024

Show notes

What led to the deadly crash of a Voepass Linhas Aereas in August? Video of the flight's final moments show the aircraft rapidly descending in a flat spin. Early reports on the accident mention that icing conditions were present in the area at the time of the crash.

Recovering from a spin in a large airliner is a significant challenge for pilots. Understanding how to avoid situations that lead to stalls and spins is the best way to avoid these tragedies.

Flight training typically does not require pilots to experience actual spins. Even full-motion simulators do not provide the full range of physical experience on an actual airplane. Pilots need to understand their aircraft's stall and spin characteristics and the situations that make an aircraft's wings more prone to stalling.
John Goglia shares his experience as an NTSB Board member investigating a 1994 icing-related crash of an ATR72. That investigation included an FAA test involving another ATR72 in controlled icing conditions, which revealed that certain icing conditions could result in icing that the ATR72's deicing system could not control.

Todd Curtis and John also delve into an incident at Boston Logan Airport where the pilot of a Brazil-registered Embraer Phenom 300E who had difficulties communicating with an air traffic controller. The pilot could not follow several ATC requests, resulting in altitude and speed deviations during a landing approach.

English is the language used by ATC at international airports, but pilots from countries where English is not the language used to communicate can have difficulties. The English used for air traffic control is not the same English used in normal conversations. Even native English speakers have challenges when communicating with ATC, particularly those performing a single-pilot IFR flight.

Related documents are available at the Fight Safety Detectives website.

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Use ASRS to Report UAP and UFO Encounters - Episode 234 Aug 14, 2024

Show notes

NASA's Aviation Safety Reporting System (ASRS) can be used by pilots, mechanics, flight attendants, and others in the aviation safety community to report UAP or UFO encounters without revealing their identity or the identity of their employers.

Todd Curtis discussed this in a June 2024 presentation at the Contact in the Desert Conference in Palm Springs, California. In this episode, he and John Goglia dig deeper into the issue of reporting of these encounters in the aviation community. While neither of them has seen an incident report that mentioned a UFO or UAP, that it does not mean that they have never happened.

Based on his experience in both industry and academia, Curtis believes that if he had come across this kind of information, he would not have included that fact in any report because it would not have been well received by his colleagues.
UAP and UFOs are legitimate risk concerns, but civilian organizations like the FAA have not formally started to collect this kind of data. Todd and John share the factors that they think are barriers to such data collection.

NASA's ASRS database already has at least 13 UAP events, each involving an unidentified phenomenon, an aerospace vehicle with unconventional capabilities, or a conventional aerospace vehicle in an unconventional location or situation. Todd and John discuss the most unusual report, involving an aerospace vehicle that was too small to carry a pilot and that exhibited extraordinary speed and maneuverability.
Anyone with an aviation-related UAP encounter should submit a report to the ASRS to help the aviation community better understand UAP risks.

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NTSB Party System Scrutinized - Episode 233 Aug 07, 2024

Show notes

Issues from the NTSB investigation of a 2023 railroad accident are used to discuss the voluntary party system. The system is designed to encourage cooperative efforts in an investigation, which does not always work.
In the party system, an organization or an individual with relevant expertise or information is invited to participate directly in an NTSB investigation. These parties are required to follow basic rules. They are expected to provide the NTSB information or expertise that helps the investigation and limit discussing details with the media and others not involved in the investigation.
In the NTSB investigation of a 2023 rail accident involving a Norfolk Southern train in Ohio, Norfolk Southern was a designated party. Late in the investigation, Norfolk Southern submitted information that the NTSB rejected because of how and when it was submitted.
Based on statements in the final report and in the public docket, Norfolk Southern did not operate properly as a party to the investigation. They conducted an independent investigation and held information that should have been given to the NTSB.
Should inappropriately late submissions be included in an NTSB investigation? The NTSB did not state if this late submission had critical information. Greg Feith and John Goglia favor analyzing all information to determine whether it helps the investigation.

Related documents are available at the Flight Safety Detectives website.

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Fireworks on a Helicopter Lead to Federal Charges- Episode 232 Jul 31, 2024

Show notes

A YouTube video showing fireworks fired from a low-flying helicopter at a speeding Lamborghini has led to federal charges for the creator.

Suk Min Choi was charged in June by the U.S. Department of Justice with one count of causing the placement of an explosive or incendiary device on an aircraft. At least four other people were involved, including two or three people in an apparent Robinson R44 helicopter and the drivers of two vehicles.
Replicating a sequence from a video game, Choi presses a “fire missiles” button while people in the helicopter shoot fireworks at the Lamborghini. In the video posted to YouTube, it appeared that there were cameras in the helicopter, the Lamborghini, and a second vehicle on the ground.

In addition to law-breaking activities, this event has scary aviation safety risks. The helicopter pilot may have violated one or more FAA regulations concerning flying for commercial purposes. And, the helicopter was clearly flown in a hazardous manner. The pilot may have problems finding employment if their involvement becomes public.
Even stunts in the air need to follow appropriate laws, regulations, and safety procedures and should be done after consulting with partners like insurance providers, the FAA, and other appropriate authorities.

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